Pregnancy of unknown location (PUL)

What does the term pregnancy of unknown location mean?

Following your appointment today, you may have been told that you have a pregnancy of unknown location. This term is used when you have a positive pregnancy test but we are unable to see a pregnancy on an ultrasound scan. This can be a confusing and frightening time, and we understand it can be difficult to take in the information explained to you at your appointment.

The aim of this leaflet is to provide you with clear information about your diagnosis. It will explain what happens next and where you can get support. Speak to your nurse or doctor if you have any concerns during the investigating process. You can also call the Early Pregnancy Assessment Unit, their numbers are listed below.

What does this mean?

There are three possible reasons why we are unable to see the pregnancy on a scan.

• The pregnancy is too early to be seen on a scan

  Pregnancy tests are now very sensitive. They can sometimes detect the pregnancy hormone as early as a few days after conception. A pregnancy sac may not be visible on ultrasound until approximately 3 weeks after conception. This is about 5 weeks after your last period. This means that the pregnancy is in the womb, but it is simply too early to see it on an ultrasound scan yet.

• An early miscarriage has occurred or the pregnancy inside the womb is failing

  It is possible that the pregnancy has already miscarried from the womb and this is why it is no longer visible. This may be the case if you have had period like bleeding.

• The pregnancy is outside of the uterus, most likely in the fallopian tube

  This is called an ectopic pregnancy. This type of pregnancy is rare and the least likely possibility. An ectopic pregnancy cannot be excluded until we can identify a pregnancy within the uterus. An ectopic pregnancy can be life threatening if it is not treated in the early stages. It is therefore very important that we investigate further.

What happens next?

You will have a blood test to help us find out what is happening in your pregnancy. We look at the level of pregnancy hormone (HCG) in your blood and how much it increases over a 48 hour period. The first blood test will be taken on the day of your appointment, you will be able to go home afterwards. You should be contacted with the result later the same day, unless you have been told otherwise by the nurse. Arrangements will then be made for you to attend for another blood test 48 hours later.

• In a normal early pregnancy that is within the uterus, we expect the hormone level to double after 48 hours. If this happens we will arrange a follow-up scan to confirm this. In almost 9 out of every 10 cases, the doubling of HCG in 48 to 72 hours is associated with a pregnancy in the uterus. However, an ectopic pregnancy cannot be completely ruled out. You will need closer monitoring to investigate with an ultrasound.

• If a miscarriage has occurred then your blood hormone level should fall. If this is the case we will provide you with information on miscarriage and ask you to carry out a urine pregnancy test at home in two to three weeks time. This is to check your hormones have returned to a pre-pregnancy level. In some very early pregnancies in the womb, which are not growing properly, the levels can stay the same or even rise slightly before they start to fall. To assess further, a repeat blood test may be needed after another 48 hours.

• In an ectopic pregnancy the hormone level may increase but it will not double, it may even stay the same. If this happens, it does not mean that an ectopic has been confirmed, but that we need to investigate a bit more. To investigate further we may ask you to attend for a repeat blood test in another 48 hours. If your blood hormone levels are where we would expect to see a pregnancy on a scan, you may be asked to attend earlier for a doctor to assess you.

Further advice

You may have mild cramping pains in your abdomen (tummy). You may also have some bleeding from your vagina while you are having investigations. Paracetamol can be taken if needed, to help with the pain. If you are coping with your symptoms and you feel well, you can stay at home during this time.

However, if:

• you have increasing or constant pains in your tummy, that are not eased by paracetamol;

• your bleeding becomes very heavy; or

• you suddenly start to feel unwell or faint,

Do not wait until your next appointment. Contact your Early Pregnancy Assessment Unit (EPAU) immediately, their numbers are listed below. If you are feeling very unwell or in an emergency you should go to the Emergency Department (ED). Emergency departments can be located at:

• Queen Elizabeth the Queen Mother (QEQM) Hospital Margate, CT9 4AN; or

• William Harvey Hospital (WHH) Ashford, TN24 0LZ.

We are keen to support you during this difficult time. If you have any questions or concerns, please contact one of the following units.

• EPAU (QEQM)
  Monday to Friday 8am to 3.30pm; Saturday 8am to 2pm
  Telephone: 01843 234469

• EPAU (WHH)
  Monday to Friday 9am to 3pm; Sunday 7am to 1pm
  Telephone: 01233 616107

Out of these hours please contact:

• Birchington Ward (QEQM)
  Telephone: 01843 234201

• Women’s Health Suite (WHH)
  Telephone: 01233 651987